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HANDBOOK for FRONTLIME WORKERS I 3 L FEMALE GENITAL MUTILATION I A HANDBOOK FOR FRONTLIME WORKERS I 3 l TABLE OF CONTENTS ACKNOWLEDGMENTS ........ Finding the right messages .............................. 54 INTRODUCTION ........... Well-planned strategies and tailored activities ....... 58 Working with the mass media .......................... 61 PART 1: WHO IS AFFECTED BY FGM? High quality training for all ..... FGM IN THE WORLD TODAY 9 ................................ 111: MEASURES OF PROGRESS ................... Definitions and classifications of FGM ................10 A vital role for research .................. How is FGM carried out? ........................... 10 Finding out what works best ................. Measuring the impact of programmes ................ 74 PART 2: WHY DO PEOPLE PRACTISE FGM? THE SOCIAL CONTEXT ....................... ......... 13 CASE STUDIES: SOME SUCCESSFUL PROJECTS The "mental mapn ........................................ 14 EGYPT: Communities monitor "at risk" girls ........ 81 What the research tells us ................................ 15 . KENYA: Communities celebrate alternative Nlgerla ..............................................15 coming of age ceremonies ............................ 83 Somalia ..... .........16 SENEGAL: Empowerment of women leads Sudan ....... ......... 17 to ban on FGM .the TOSTAN experience ...87 Egypt ........ ......... 18 UGANDA: The REACH Programme . celebrating cultural identity ............... PART 3: THE HEALTH CONSEQUENCES OF FGM A DANGEROUS PRACTICE ..................................23 COMMENTS AND RECOMMENDATIONS What the research tells us ............. .............. 23 COMMENTS AND RECOMMENDATIONS .............95 Immediate complications ..... ......... 23 LIST OF ACRONYMS ...........................................97 Long-term complications ............... ......... 25 Problems in pregnancy and childbirth .............. 28 ANNEXES: Psychological and sexual consequences of FGM . 29 1. International action ... PART 4: FGM PREVENTION PROGRAMMES: LESSONS FROM THE FIELD HIGHLIGHTED TEXT I: STRONG FOUNDATIONS ........ ......... 35 Players in the field ........................................35 'Itvo women tell their stories ................. Laws and policies to protect women and girls ........37 The Inter-Africa Committee on Harmful Making FGM a mainstream issue ...................... 40 Traditional Practices at work in Burkina Faso Training for health care providers ...................... 41 and Ethiopia ............................................36 Coordination between anti-FGM organizations ..... 42 FGM and the law .......................................... 38 .... .. -p- A central role for advocacy .............................. 43 To pass a law or not to pass a law? ...................... 39 A physician speaks out ................................... 41 11: COMMUNICATION AND BEHAVIOUR Egypt's "New Horizonsn Project .................... 50 CHANGE ......................................................... 46 The dangers of focusing on FGM as a A role for all players ...................................... 48 health issue .............................. A focus on youth ....... ......... 49 A focus on human rights in Egypt .......... A focus on urban elites ..................... Mali fosters community decision-making A limited role for traditional excisors .................. 51 over FGM ...................................... Building on positive community values ............... 52 Some pitfalls to avoid ..... FEMALE GENITAL MUTILATION 1 4 1 A HANDBOOK FOR FROMTLINE WORKERS ACKNOWLEDGMENTS The World Health Organization (WHO) wishes to thank the following teams and collaborating institutions and organizations for the reviews on: (a) FGM programmes: Asha A. Mohamud, Nancy A. Ali and Nancy Yinger (Program for Appropriate Technology in Health (PATH); (b) socio-economic and cultural aspects: Dr Rhetta Moran, Dr Hermione Lovel, MS Zeinab Mohammed (University of Manchester) and Dr Margaret Njikam Savage (University of Douala); and (c) on the health complications: Dr Hermione Lovel, Dr Claire McGettigan, MS Zeinab Mohammed (University of Manchester) WHO gratefully acknowledges the support provided by the WHO Regional and Country Offices for the Eastern Mediterranean and Africa, the many individuals and the network of researchers in countries who contributed to the reviews. WHO also gratefully acknowledges the financial support of AUSaid, DFID and UNFIP for the project. Acknowledgments to Efua Dorkenoo, Department of Women' S Health, WHO for initiating the project, coordinating key technical inputs into all the reviews and bringing together the information into one document. Thanks goes to Jillian Albertolli for administrative support. Special thanks also go to Sue Armstrong for editing of the handbook. Design: Mr Caleb Rutherford - eidetic Photos: WHO O World Health Organization, 2000 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. Department of Women's Health Family and Community Health World Health Organization Geneva FEMALE GENITAL MUTILATION AH~OOKFORFRONTLINE WORKERS 1 5 1 INTRODUCTION Until relatively recently, scientists, the international organizations asking for information on their anti- community and national governments turned a blind FGM programme strategies and activities, staffing, eye towards female genital mutilation (FGM), sources of funds, target audiences, materials unwilling to tackle an issue of such extreme sensitivity. developed, evaluation, difficulties experienced and The few people who did try to investigate and lessons learnt. 102 questionnaires were returned, and challenge the practice met with such a strong and the information from 88 organizations particularly hostile reaction from communities where FGM was active in the field was analysed in depth. Subsequently, the tradition that most quickly dropped the matter. PATH researchers visited five African countries with However, a number of concerned individuals and strong programmes. These were Burkina Faso, Egypt, organisations persisted with their challenge, and their Ethiopia, Mali and Uganda. In addition to the country tireless advocacy has borne fruit. Today, there is wide visits, the researchers looked in depth at specific recognition at global and national levels of the harmful projects in Kenya and Senegal. effects of FGM and of the pressing need for systematic Aware of the fact that the elimination effort is action to accelerate the elimination of the practice. hampered by major gaps in understanding why Over the past two decades, FGM prevention communities practise FGM and what effects the programmes have been established in most countries different types have on health, WHO also where this is practised. They are working today at the commissioned literature reviews of the social, level of policies and laws as well as at the grassroots economic and cultural context of FGMZ,and its health among communities where FGM is the tradition. consequences3from teams at Manchester University. What strategies have these programmes used? What The purpose of this handbook is to share with have been their strengths and weaknesses? And what readers the key findings of these research projects. The have they learnt from experience that would be useful aim is to increase the effectiveness of prevention to others in the field? In order to answer these campaigns at all levels by increasing understanding of questions and to identify the actions and ideas that the practice, and by identifying what does and does not should be given priority support, the World Health work in the field and why. The handbook is intended Organization (WHO) commissioned the Program for primarily for non-governmental organizations (NGOs) Appropriate Technology in Health (PATH) to carry out committed to the elimination of FGM, and for others a review1 of anti-FGM programmes operating mostly working at the frontline with communities that practise in countries in Africa. it, for example health service personnel. But it should The review consisted of a detailed questionnaire be of interest, also, to those responsible for policy- sent out to 365 national and international making in this field at national and international levels. ' "Female Genital Mutilation. Programmes to date: what works and what doesn't. A review': The original report, ref. WHOICHSIWMH199.5, can be obtained from the Department of Women's Health at WHO, Geneva. ''!A framework for the analysis and collation of primary data on the sodo-economic-culturalaspects of female genital mutilation". (Unpublished report), Department of Women's Health, WHO, Geneva. ' "A systematic review of research on health complications following female genital mutilation including sequelae in childbirth",The original report, ref. WHO/FCH/WMH/OO.Z, can be obtained from the Department of Women's Health at WHO, Geneva. FEMALE GENITAL MUTILATION 1 6 1 A HAND.ooK m FRONT,,.. ,ME, I The handbook is divided into four parts: Part 1 discusses what is known about the extent of FGM and where it is practised today: Part 2 looks at the attitudes and beliefs that underpin FGM; Part 3 looks at the health consequences associated with the different types of FGM; Part 4 describes existing
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